Citation Nr: 1306134 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 10-22 402A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for diabetes mellitus type 2, claimed as secondary to a service-connected deviated septum. 2. Entitlement to service connection for a heart disorder, claimed as secondary to a service-connected deviated septum. 3. Entitlement to a rating in excess of 10 percent for a deviated septum. 4. Entitlement to a rating in excess of 10 percent for anosmia. 5. Entitlement to a compensable rating for hypogeusia. 6. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from June 1975 to June 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2008 and March 2010 rating decisions of the Providence RO. In February 2010, the Veteran testified at a local hearing before a Decision Review Officer (DRO). In May 2012, the Veteran testified at a Travel Board hearing before the undersigned. Transcripts of these hearings are associated with the claims file. Regarding the issue involving service connection for diabetes mellitus, the Board notes that matter was initially adjudicated on a direct basis in a June 2008 rating decision. After a notice of disagreement was received, the Veteran testified at the February 2010 DRO hearing and his representative clarified the issue as being secondary to the deviated septum. Although the RO proceeded to adjudicate the issue as a new claim from that point forward, the Board finds that the proper treatment of his testimony is to consider it a new theory of entitlement rather than a new claim. Thus, the matter stems from the June 2008 and March 2010 rating decision rather than just the March 2010 rating decision. The Veteran's electronic ("Virtual VA") file was reviewed and it does not contain any evidence or information that has not been considered by VA. The Veteran contends that disabilities manifested by a loss of the sense of smell and taste impair his employability. In particular, he asserts that he could no longer work as a cook due to the loss of his sense of smell or taste. See VA treatment records dated in March 2010 and May 2012 hearing testimony. Thus, the Board finds that the record has raised a claim for TDIU as an included claim within the Veteran's currently pending increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). This issue has been added as an additional subject for current appellate consideration. The issues of service connection for a heart disorder, entitlement to a rating in excess of 10 percent for a deviated septum, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's diabetes mellitus type 2 was not manifested in service or within the first post-service year, was not manifested until many years after service, and is not related to service or caused or aggravated by the service-connected deviated septum. 2. For the entire rating period, the Veteran's loss of sense of smell involved the total or near total inability to smell. 3. For the entire rating period, the Veteran's loss of sense of taste involved near total inability to taste. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type 2, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a rating in excess of 10 percent for loss of sense of smell have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.87a, Diagnostic Code (DC, or Code) 6275 (2012). 3. The criteria for a 10 percent rating for loss of sense of taste have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.87a, Code 6276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). Letters dated in December 2007, April 2008, January 2009, February 2010, and October 2010 informed the Veteran of all the elements required by 38 C.F.R. § 3.159(b), as stated above. In this regard, the RO notified the Veteran and his representative of the information and evidence needed to substantiate the Veteran's claims. The Veteran was told what evidence was needed to establish service connection, to include on a secondary basis, and that the evidence must show that his service-connected disabilities had gotten worse and increased in severity. Regarding the duty to assist, service treatment records are associated with his claims file and VA has obtained all pertinent records that could be obtained. The RO also arranged for VA examinations for the increased rating claims, most recently in March 2010, that are adequate for rating the service-connected disabilities. Barr v. Nicholson, 21. Vet. App. 303 (2007). Regarding service connection for diabetes mellitus, the Board acknowledges that, to date, VA has neither afforded the Veteran an examination, nor solicited a medical opinion; however, no VA examination is necessary to satisfy the duty to assist in this case. Under 38 U.S.C.A. § 5103A (d)(2), VA must obtain a medical examination or opinion when such is necessary to make a decision on a claim. Specifically, a VA examination is required where the record contains competent evidence of a current disability, and indicates that the disability or symptoms may be associated with military service, but does not contain sufficient evidence for the Secretary to make a decision. Id. In this regard, the Board notes that, as discussed below, there is no opinion of record. The Veteran was notified throughout the appeal process that nexus evidence was needed to support the claim of service connection for diabetes mellitus type 2, but none has been submitted. Furthermore, there is evidence of record that is contrary to the Veteran's assertion as to etiology, and this evidence is sufficient to decide the claim. The Veteran is competent to state that he has trouble breathing through his nose and that he became less active and gained weight. However, the Board finds that the Veteran is not credible in this regard, as discussed in more detail below. In such circumstances, there is no duty to obtain a medical examination or opinion. McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The statutory duty of VA to assist Veterans in developing claims does not include a duty to provide a Veteran with a medical examination and medical opinion absent a showing of a causal connection. 38 U.S.C.A. § 5103A (a, d); Wells v. Principi, 326 F.3d. 1381 (Fed. Cir. 2003). Accordingly, the duty to assist has been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Service Connection Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). A veteran may be granted service connection for any disease initially diagnosed after discharge, but only if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 3.102. The Veteran contends that his diabetes mellitus is secondary to his deviated septum. In particular, he testified that his diabetes was due to being less active. He stated that he used to run, but that since he was not able to breathe as a result of the deviated septum he ran less and became more inactive. He asserts that his inactivity led to weight gain, which in turn led to the development of diabetes mellitus. Secondary service connection shall be awarded when a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. §§ 3.310(a). Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Reiber v. Brown, 7 Vet. App. 513, 515-16 (1995); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Here, two of the three elements to establish secondary service connection are met. The Veteran's deviated septum is a service-connected disability and the record contains ample evidence to establish a diagnosis of diabetes mellitus. See October 2007, September 2009, and April 2010 VA treatment records. The Veteran is competent to state that he has trouble breathing through his nose and that, as a result, he became less active and gained weight. However, the Board finds that the Veteran is not credible to the extent that he attributes an inability or decrease in his exercise to difficulty breathing associated with his deviated septum. The evidence contradicts the Veteran's contentions. The record shows that the Veteran is obese and that he has been so for many years. See the June 1998 VA examination. However, the evidence does not show that that the obesity was caused by the deviated septum and/or difficulty breathing through his nose. The evidence of record dates back to 1996 and indicates that his weight gain was not caused by his deviated septum. In this regard, there are many treatment records that note the Veteran's increased weight gain and show that he was advised to lose weight through exercise. See Treatment records dated in March 1996, July 1997, August 1997, October 2008, January 2009, September 2009, and April 2010. In April 2010, it was noted that he had started going to the gym. He was also shown to have successfully lost weight and that he has done so through exercise. See January 1997 and January 2002 VA treatment records and the February 2008 VA examination report. The fact that he was advised on many occasions to exercise and that he lost weight through exercise is very probative and shows that his deviated septum does not preclude physical activity. On VA examination in February 2008, it was noted that he had lost 43 pounds in the past 12 months. Therefore, the Board finds that the Veteran's obesity/weight gain is not shown to have been caused or aggravated by his deviated septum. In the present case, there is no competent and credible evidence to support the Veteran's contention that his diabetes mellitus was caused or aggravated by his deviated septum. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of diabetes mellitus, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board notes that the Veteran has presented articles that indicate that there is an association between diabetes and obstructive sleep apnea, and between sleep loss and obesity and diabetes. However, the Veteran is not service connected for obstructive sleep apnea; therefore, these articles are not probative as to the issue on appeal. With regard to direct service connection, the Veteran does not contend, and the evidence does not show, that he had diabetes mellitus in service or within one year of service. Accordingly, a presumption of service connection for diabetes mellitus as a chronic disease pursuant to the provisions of 38 C.F.R. §§ 3.307 and 3.309(a) is not warranted. The Veteran's service treatment records are silent for complaints, findings, or diagnosis of diabetes mellitus. The record shows that this disorder was diagnosed many years after service. See September 2001 and September 2007 VA treatment records. The Veteran has not reported a continuity of symptomatology since service, and there is no medical evidence of record showing that diabetes mellitus had its onset during service or is related to any in-service disease, event, or injury. For the reasons stated, the Board finds that since the evidence weighs against the claim for service connection for diabetes mellitus, to include as secondary to a deviated septum, the benefit-of-the-doubt doctrine does not apply and the claim is denied. III. Increased Rating Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Although the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. However, as discussed below, in this case, the record reflects that the Veteran's disability has remained constant with respect to the applicable schedular criteria. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. A. Anosmia Service connection for anosmia was established in a February 2000 rating decision and a noncompensable rating was assigned. An October 2002 rating decision increased the rating of the disability to 10 percent. The Veteran's anosmia is rated under 38 C.F.R. § 4.87a, Code 6275, which provides a maximum schedular rating of 10 percent for "complete loss of sense of smell". There is no schedular basis for a higher rating. The Rating Schedule does not contain any other potentially applicable provisions under which the Veteran's disability could be rated. Schafrath, supra. As such, there is no means by which to assign a scheduler rating in excess of 10 percent for any period during the appeal. For this reason, the Board finds that the preponderance of the evidence is against an initial rating in excess of 10 percent for the Veteran's service-connected loss of sense of smell for any period. Id.; 38 C.F.R. § 4.87a, Diagnostic Code 6275; see also Hart, supra. The Board has been mindful of the "benefit-of-the-doubt" rule, but in this case, there is not such an approximate balance of the positive evidence and the negative evidence to permit a favorable determination. 38 C.F.R. §§ 4.3, 4.7. The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Concerning the matter of an extraschedular rating for the Veteran's loss of sense of smell, the Board finds that the schedular rating criteria contemplate the symptoms experienced by the Veteran. The rating criteria specifically provide for a maximum rating of 10 percent for the total loss of the sense of smell, which is nearly or precisely the extent of the Veteran's disability. He has complained of a loss of smell, and this is specifically contemplated by the 10 percent rating assigned under DC 6275. The schedular rating criteria even contemplate the underlying anatomical or pathological basis for the anosmia. See 38 C.F.R. § 4.87a Note. For these reasons, referral for consideration of an extraschedular rating is not warranted for this claim. B. Hypogeusia Service connection for hypogeusia was established in a February 2000 rating decision and a noncompensable rating was assigned. Pursuant to 38 C.F.R. § 4.87a, Code 6276 provides a maximum 10 percent rating for a complete loss of sense of taste. The Veteran underwent VA examinations in February 2008 and March 2010. In 2008 the examiner diagnosed "loss of taste", but did not state whether or not the loss was complete or partial. In March 2010, indicates that he tasted very few things and that he over seasoned all of his food. In May 2012, he testified that if he enjoyed food then it was due to the texture and that he lost 99.9 percent of his ability to taste food. Based on his hearing testimony, the Veteran essentially has complete loss of taste. Since he is competent to report that he cannot taste, he is afforded the benefit-of-the-doubt and a 10 percent rating is assignable throughout the entire appellate period. See Hart, supra. This is the maximum schedular rating available under DC 6276. The Rating Schedule does not contain any other potentially applicable provisions under which the Veteran's disability could be rated. Schafrath, supra. As such, there is no means by which to assign a scheduler rating in excess of 10 percent for any period during the appeal. For this reason, the Board finds that the preponderance of the evidence is against an initial rating in excess of 10 percent for the Veteran's service-connected loss of sense of taste for any period. Id.; 38 C.F.R. § 4.87a, Diagnostic Code 6276; see also Hart, supra. The Board has been mindful of the "benefit-of-the-doubt" rule, but in this case, there is not such an approximate balance of the positive evidence and the negative evidence to permit a favorable determination. 38 C.F.R. §§ 4.3, 4.7. Concerning the matter of an extraschedular rating for the Veteran's loss of sense of taste, the Board finds that the schedular rating criteria contemplate the symptoms experienced by the Veteran. The rating criteria specifically provide for a maximum rating of 10 percent for the total loss of the sense of taste, which is nearly or precisely the extent of the Veteran's disability. He has complained of a loss of taste, and this is specifically contemplated by the 10 percent rating assigned under DC 6276. For these reasons, referral for consideration of an extraschedular rating is not warranted for this claim. 38 C.F.R. § 3.321(b)(1). ORDER A rating in excess of 10 percent for loss of sense of smell is denied. A 10 percent rating for hypogeusia is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board finds that additional development is needed with regarding the issues that remain on appeal. The Veteran contends that his heart disorder was caused or aggravated by the service-connected deviated septum. In May 2012, he testified that during an ENT examination he was told that his heart disorder was related to his deviated septum. His representative indicated that he received this information verbally and that it was not written in his record. Although there is no documentation to corroborate this testimony, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held in Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed.Cir.2006), that "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence," and that "competent lay evidence can be sufficient in and of itself" to support a finding of service connection. Notably, lay testimony regarding what a medical professional tells a lay person is specifically listed as one of the examples given as competent lay testimony. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). Although the Veteran may be competent to report that he was told that there is a nexus between the claimed heart disorder and his deviated septum, this testimony is insufficient to grant the claim. In this regard, the transcript does not clearly reflect the underlying rationale or indicate the extent of the medical provider's familiarity with the Veteran's medical history. Nevertheless, the evidence is sufficient to trigger the need for a VA examination and opinion. Regarding the service-connected deviated septum, the Veteran reported that he received all of his treatment through the Providence VA Medical Center (VAMC) and that he had an ENT appointment in June 2012. This record is not associated with the claims file. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically in the claims files. Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The record also shows that the Veteran indicated that he had an ENT appointment at Rhode Island Hospital and/or University Otolaryngology in 2010. This record is not associated with the claims file and since it may be pertinent to the appeal, the evidence must be sought. Finally, with respect to the TDIU claim, on remand, the RO should send the Veteran a VCAA notice letter and obtain a medical opinion, as set forth below. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran about (1) the information and evidence not of record that is necessary to substantiate his claim for a TDIU; (2) the information and evidence that VA will seek to obtain on his behalf; and (3) the information or evidence that he is expected to provide. A copy of this notification must be associated with the claims folder. 2. Obtain all pertinent medical records from the Providence VAMC dated since October 2010, to specifically include record of a June 2012 ENT appointment. 3. Contact the Veteran and request that he submit a completed authorization for University Otolaryngology and/or Rhode Island Hospital in reference to ENT treatment he received at this facility in 2010. Make arrangements to obtain the Veteran's records from this facility(ies). 4. After the foregoing development has been completed, schedule the Veteran for a VA heart examination. The claims file must be made available to and reviewed by the examiner. All necessary tests should be performed. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's currently diagnosed heart disorder was caused by the service-connected deviated septum. The examiner must also specifically address the Veteran's contention that his deviated septum caused breathing difficulty that overworked his heart and caused his heart disorder. If the examiner's response to causation is negative, then the examiner must provide an opinion as to whether it is at least as likely as not that the currently diagnosed heart disorder has been aggravated by the service-connected deviated septum. In this special context, the Board notes that "aggravation" has occurred when it has been medically determined that the Veteran's heart disorder has undergone an identifiable permanent increase in severity that was proximately due to his service-connected deviated septum. The examiner must also specifically address the Veteran's contention that his deviated septum caused breathing difficulty that overworked his heart and aggravated his heart disorder. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 5. Schedule the Veteran for an appropriate examination to determine whether his service-connected disabilities render him unable to secure or follow a substantially gainful occupation. The claims file must be made available to and reviewed by the examiner. All necessary tests should be performed. The examiner must provide an opinion as to whether the Veteran's traumatic deviated septum, anosmia, and hypogeusia, either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by nonservice-connected disabilities are not to be considered. The examiner must provide a comprehensive report including complete rationale for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 6. Next, review the claims file to ensure that the foregoing requested development has been completed. In particular, thoroughly review the VA examination reports to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. 7. Finally, readjudicate the Veteran's claims on appeal. If any benefit sought on appeal is not granted in full, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs